Lectures on Gynecology

Dr Magda Helmi

Genital infections are one of the most common reasons

for women of all age groups to present to a medical

practitioner.

Sexually transmitted infections form one subgroup of

infections, however the more common infections are

vulvovaginal candidiasis and bacterial vaginosis.

Chlamydia and gonorrhoea affect the sexually active

woman, with HlV.

These infections can be asymptomatic and can have

serious consequences to a woman’s fertility by causing

tubal infection and damage.

Appropriate diagnosis and treatment are fundamental

not only to provide symptom relief, but also to prevent

recurrences and long-term squeals

It is important to differentiate normal

physiological

changes from true infections. Thus, a thorough

history and examination with the back up of

laboratory testing is fundamental before a

diagnosis is made.

However, the sensitivity of clinical diagnosis

and testing in pelvic inflammatory disease

(PID)

can be low, so if there is a clinical suspicion of

PID,

empiric treatment is recommended.

Anatomy and physiology:The vaginal epithelium is lined by stratified squamous epithelium during the

reproductive age group under the influence of oestrogen. The pH is usually

between 3.5 and 4.5 and lactobacilli (Figure 6.1a) are the most common

organisms present in the vagina. Following the menopause, the influence of

oestrogen is diminished making the vaginal epithelium atrophic with a more

alkaline pH of 7.0, the lactobacillus population declines and the vagina is

colonized by skin flora.

Physiological discharge occurs in response to hormonal levels during the

menstrual cycle. It is usually white and changes to a more yellowish colour due

to oxidation on contact with air.

There is increased mucous production from the cervix at the time of ovulation

followed by a thicker discharge/cervical plug under the influence of

progesterone. The discharge mainly consists of mucous, desquamated

epithelial cells, bacteria (lactobacillius) and fluid.

Ascending infection can occur from the vagina and cervix to the uterine cavity

and to the Fallopian tubes through direct spread or via the lymphatics leading

to severe pelvic inflammatory disease and pelvic peritonitis.

Infections can be broadly divided into lower and upper genital tract depending

on the site and affection of the infective organism.

Vaginal and cervical flora (all ><1000 magnified). Normal: lactobacilli - seen as large Gram-positive rods

- predominate. Squamous epithelial cells are Gram negative with a large amount of cytoplasm. (b) Cnandidiasis: (c) (d) :

Lower genital tract

infectionsVulvovaginal candidiasisCandida, a commensal organism, is found in

small population densities in the vaginal

ecosystems of nearly one third of healthy

women. Symptomatic infection arises,

however, when proliferation causes a shift

from colonization to frank adherence and

infection. It is caused by Candida albicans in

around 80-92 per cent of cases. Other non

albican species like C.tropicalis, C. glabmta,

C. krusei and C. parupsilosis can also cause

similar symptoms, although sometimes more

severe and recurrent. C. albicans is a diploid

fungus and is a common commensal in the

gut flora.

The patent complain of: Vulval itching and

soreness, thick curdy vaginal discharge

dyspareunia and dysuna. Vulval oedema,

vulvai excoriation, redness and erythema.

Normal vaginal pH,

there are speckled Gram-positive

spores and log pseudohyphae visible.

There are numerous polymorphs

present and the bacterial flora is

abnormal, resembling bacterial

vaginosis.

Microscopy of the discharge with

10% KOH will often reveal hyphae

or budding yeast in 50%-70% of

cases albicans organisms are

easiest to identify, as they have

long hyphae with blastospores

along their length and a terminal

cluster of chlamydiaspores . The

"atypical" species of yeast,

however, may only have features

of budding yeast (resembling

small snowmen), which are easily

obscured within surrounding

cellular debris.

The trichomonad parasite is a flagellated protozoan that causes up to 25% of vaginitiscases. While trichomonasinfection is asymptomatic up to 50% of the time,when clinical signs are present they include irritation and soreness of the vulva, perineum, and thighs, with dyspareunia and dysuria. Typically, the trichomonasinfection is accompanied by a copious, greenish-yellow frothy discharge. Unlike bacterial vaginosis, it seems that trichomonas is primarily a sexually transmitted infection.

. The diagnosis is made by observation of the following features (Table I):A foul-smelling frothy discharge (present in 35% of casesVaginal pH >4.5 (70% of cases)Punctate cervical microhemorrhages(25%)Motile trichomonads on wet mount (50%-75%)Papanicolaou smear is quoted to be 70% sensitive in identifying trichomonads.The current primary treatment recommendation is a single 2g dose of oral metronidazole. For those who cannot tolerate this single large dose, 500mg bid for 7 days is equally efficacious if the patient completes her regimen. The male partner(s) must also receive treatment.

Bacterial vaginosis: there is an overgrowth of anaerobic organisms, including Gardnere/Ia vagina/is (small Gram-variable cocci), and a decrease in the numbers of lactobacilli. A 'clue cell’ is seen.

On wet preparation of vaginal fluid, absence of WBCs and stippling of epithelial cells support a diagnosis of bacterial vaginosis.

The diagnosis of BV requires the presence of at least 3 of the following 4 criteria.A homogenous noninflammatory discharge (not many WBCs).

Vaginal pH >4.5.Clue cells (bacteria attached to the borders of epithelial cells, >20 % of epithelial cells; Whiff test positive for fishy or musty odor when alkaline KOH solution added to smear.

For years, oral metronidazole has been the primary indicated regimen. Other systemic options include oral clindamycin.

Pap smear showing clue cells consistent with bacterial

vaginos

According to 2008 WHO estimates,

499 million new cases of curable

sexually transmitted infections (ie,

syphilis, gonorrhoea, chlamydia,

trichomoniasis) occur annually

throughout the world in adults aged 15-

49 years.

Tubal scarring as a result of PID can

cause infertility in 20%, ectopic

pregnancy in 9%, and chronic pelvic

pain in 18% of women[

Complicated PID resulting in tubo-

ovarian or pelvic abscess may

contribute to patient mortality.

PID is a complex polymicrobial disease that is due to the ascending spread of pathogens from the cervix or vagina, most commonly Chlamydia, trachomatis or Neisseriagonorrhoeae (60-75%) , which then spreads into the endometrium, fallopian tubes, ovaries, and adjacent structures.Other pathogens include Mycoplasmahominis, Haemophilusinfluenzae,Streptococcuspyogenes, Bacteroides species, and Peptostreptococcus species. Less commonly, direct spread from a nearby infection such as appendicitis ordiverticulitis may occur. Hematogenous infection is a rare cause of PID except in cases of tuberculous.Douching is a potential risk factor for PID as it can result in a change of the vaginal flora and introduce bacteria from the vagina into the upper reproductive organs. Usage of intrauterine contraceptive device or gynecologic interventions may also predispose a patient to PID. Direct extension of infection from adjacent viscera and uterine instrumentation are more important risk factors in postmenopausal PID

Abdominal, pelvic pain and dyspareunla.

Mucopufulent vaginal discharge

Pyrexia (>38‘C). Heavy/ime.rmenslrual

bleedlng Pelvic tenderness and Tender

adnexal or palpable pelvic mass,

Generalized sepsis in severe and sysmmic infection

Tubal damage leading to tubal occlusion, abscess and hydrosalpinx.

Based on clinical findings:

Raised white cell count (neutrophilia

suggestive of acute inflammatory

process)

Reduced white cell count

(neutropenia in severe infections)

Raised C reactive protein and ESR

(erythrocyte sedimentation rate)

Adnexal masses on ultrasound

Laparoscopy is the gold standard to

give a definitive diagnosis, however,

in mild cases it may

not be very obvious.

Depending on the severity of the infection, patients with mild/moderate disease can be managed on an outpatient basis with easy access to hospital admission if the infection becomes more severe. An intrauterine contraceptive device, if present, should be removed and alternative emergency contraception or other modes of contraception (combined pill, oral/parenteral progesterone) should be offered. A

pregnancy test should be done in all cases to rule out ectopic pregnancy. There are several differing antibiotic regimes that are used; however, the

following is recommended by the RCOG Green Top Guideline (2008) which is evidence based.

Mild/moderate infection (outpatient treatment) Oral ofloxacin 400 mg twice a day + oral metronidazole 400 mg twice a day x 14 days Ceftriaxone 250 mg single intramuscular injection + oral doxycycline 100 mg

twice a day oral metronidazole 400 mg twice a day x 14 days Single intramuscular dose of ceftriaxone 250 mg azithrornycin 1 g/week x 2

weeks. The data supporting the use of azithromycin are limited and should not be used

in isolation.

Causative organism

Herpes simplex virus type I (usually oral) or

type II (usually genital).

Clinical features

Painful vesicles and multiple ulcerations on

vulva, Retention of urine.

DiagnosisSwab from ulcer, Serum from vesicle, Virus

seen on electron microscopy, Culture.

TreatmentAcyclovir 200 ml five times/ day

Famciclovir, Valaciclovir,

Analgesics and local unaesthetic gels

Causative organism:Human papillomavirus, HPV6and11, HPV 16 and 18, linked to cervical caner.

Clinical features:Warty lesions on the vulva, vagina, cervix and perianalarea.Also seen around mouth, lips and larynx if orogenitalcontact.

Diagnosis:Clinical examination:Histology of removed wart Seen on cervical smear and

colposcopyTreatment:

Podophyllin; local application twice a week, Surgical excision, Laser, Cryotherapy.

Causative organism:Treponema pallidumClinical features:Primary syphilis: Painless ulcer/ulcers on vulva, vagina or cervix, Enlarged

groin/inguinal lymph nodesSecondary syphilis: maculopapular, rash on palms and soles. Mucous

membrane ulcers, Generalized lymphadenopath, arthritisNeurosyphilis: meningitis, strok, tabes dorsalisCardiovascular: aortic aneurysmCongenital syphilis: intrauterine death, interstitial keratitis, VIII nerve

deafness, abnormal teethDiagnosis:TPPA: Treponema pallidum particle agglutination.TPHA: Treponema pallidum haemagglutinatio assay.FTA: Fluorescent treponemal antibody.Dark Held illumination: serum from base of ulcer + saline taken and seen

under the microscope. Spiral organisms with characteristic movements are diagnostic

Treatment:Penicillin mainstay of treatment Procaine, penicillin, 1.2 MU daily, i.m. x

12 days, Benzathine penicillin, 2.4 MU i.m. repeated after 7 days.Doxycycline 100 mg bd x 14 days.Erythromycin 500 mg qds x 14 days mm.

Causative organism:Mycobacterium tuberculosis.

Clinical features:

Usually following pulmonary tuberculosis through blood and lymphatics,

Amenorrhoea (affects endometrium) Infertility (affects tube), Acute/ chronic pelvic

pain, Frozen pelvis due to severe multiple adhesions.

Diagnosis:

Histological confirmation from endometrium and Fallopian tube, Mantoux test, Heaf

test, Chest x-ray.

Treatment:

Rifampicin, Isoniazid, Pyrazinamide. Treatments can, last from six to 12 months.

Causative organism:Haemophilus ducreyi.

Clinical features:Painful shallow multiple ulcers, Regional

lymphadenopathy with suppuration.

Diagnosis:

Isolation of Ducrey’s bacillus on biopsy on

biopsy.

Treatment:

Single oral dose of azethromycin, Ceftriaxone,

Erythrofpycin.

Causative organism:

Klebsiella grarnulomatoses.

Clinical features:

Painless nodule.

Diagnosis:

Donovan bodies:intracellular inclusions seen in

phagocytes or histiocytes.

Treatment:

Erythromycin.

Painful ulcers, Local tissue, destruction, treated with Streptomycn,

tetracyclin

ONE IS TERMED LACTOBACILLOSIS OR

DÖDERLEIN CYTOLYSIS. THIS ENTITY IS

CHARACTERIZED BY AN OVERGROWTH OF

THE COMMENSAL LACTOBACILLI HENCE,

ON SALINE WET MOUNT, ONE FINDS AN

EXCESSIVE NUMBER OF BACILLI AMONG

THE BACKGROUND FLORA. THE PH IS

TYPICALLY LOW-NORMAL. TREATMENT,

THEREFORE, IS DIRECTED AT

CORRECTING THE DISRUPTION OF THE

VAGINAL ECOSYSTEM IN ORDER TO LIMIT

THE EXCESSIVE PROLIFERATION OF

THESE PROTECTIVE ORGANISMS.

INFLAMMATORY VAGINITIS, FEATURES A

VAGINAL PH ABOVE 4.2, LARGE NUMBERS

OF LEUKOCYTES, AND SOME PARABASAL

AND BASAL VAGINAL CELLS, WITH A

PAUCITY OF SUPERFICIAL SQUAMOUS

CELLS. CLINICIANS OFTEN FIND THAT

PATIENTS ARE INFECTED WITH GROUP A

OR GROUP B STREPTOCOCCUS

THEREFORE, BECAUSE INFECTION IS

SUSPECTED TO UNDERLIE THE

INFLAMMATION AND DESQUAMATION,

TREATMENTS DIRECTED AGAINST

BACTERIAL VAGINOSIS ARE

RECOMMENDED.